Provider Demographics
NPI:1407386634
Name:MORRILL, JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MORRILL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 JERICHO RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2745
Mailing Address - Country:US
Mailing Address - Phone:802-355-2314
Mailing Address - Fax:
Practice Address - Street 1:26 CANADA ST
Practice Address - Street 2:
Practice Address - City:SWANTON
Practice Address - State:VT
Practice Address - Zip Code:05488-1335
Practice Address - Country:US
Practice Address - Phone:802-868-2454
Practice Address - Fax:802-868-2461
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant